Nrs 340 Exam 2

A nurse is developing a plan of care for a client who has conversion disorder. Which of the following actions should the nurse include?

Discuss alternative coping strategies with the client.

A nurse is preparing to assess an infant who has shaken baby syndrome. Which of the following is an expected finding?

Respiratory distress, retinal hemorrhage, altered level of consciousness, increase in head circumference.

A nurse working in an emergency department is assessing a preschool age hold who reports abdominal pain. When conducting a head to toe assessment, which of the following findings should alert the nurse to possible abuse?

Round burn marks on forearms, areas of ecchymosis on torso.

A nurse is caring for a client who has bipolar disorder. The client states, "I am very rich, and I feel I must give my money to you." Which of the following responses should the nurse make?

"I am here to provide care and cannot accept this from you.

Sasha is a 38-year-old patient admitted with major depression. Which of the following statements Sasha makes alerts you to a common accompaniment to depression?

"I still feel bad about my sister dying of cancer. I should have done more for her!"

Sasha is started on fluoxetine. Which statement by Sasha indicates that she understands the medication teaching you have provided?

"I will report any symptoms of high fever, fast heartbeat, or abdominal pain to my provider right away."

Tyler's nursing care plan has several nursing diagnoses listed. Match the nursing diagnosis to the level of priority

1. Risk for injury 2. Self care deficit 3. Knowledge 4. Nonadherence

A nurse is caring for a client who has acute stress disorder and is experiencing severe anxiety. Which of the following statements should the nurse make?

Tell me about how you are feeling right now.

Which of the following statements about dissociative disorders is true?

Dissociative symptoms are not under the person's conscious control.

A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

Stay with the client and remain quiet.

A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects?

Voice changes, dysphagia, neck pain

You are working with Ava, another student nurse on the psychiatric unit. She tells you she doesn't want to ask her patient about suicidal ideation because "It might put ideas in her head about suicide." Your best response would be:

"Actually, it's a myth that asking about suicide puts ideas into someone's head."

Erin has just been diagnosed with dissociative identity disorder. She asks you, "What exactly are 'alters'? My provider told me I have several of them." Which statement by Erin illustrates that the education you provided has been effective?

"So, alters are separate personalities with their own characteristics that take over during stress."

Clonidine

-alpha 2 agonist (❤️ med) -may decrease BP and pulse -may cause dry mouth

Prazosin

-treat nightmares and daytime symptoms related to PTSD -alpha1 adrenergic antagonist (❤️ med) -SE: hypotension or orthostatic hypotension

Sasha's roommate Kate was admitted with major depression and suicidal ideation with a plan to overdose. Kate is preparing for discharge and asks you, "Why did Dr. Travis give me a prescription for only 7 days of amitriptyline?" Your response is based on the knowledge that:

Amitriptyline is lethal in overdose

A nurse working in an acute mental health facility is caring for a 35 year old female client who has manifestations of depression. The client lives at home with her partner and two young children. She currently smokes and has a history of chronic asthma. Which of the following factors put the client at risk for depression?

Age, gender, history of chronic asthma, smoking

A nurse is discussing routine follow-up needs with a client who has a new prescription for valproate. The nurse should inform the client of the need for routine monitoring of which of the following?

AST/ALT and LDH

A community health nurse is leading a discussion about rape with a neighborhood task force. Which of the following statements by a neighborhood citizen indicates an understanding of the teaching?

Acquaintance rape often involves alcohol.

A nurse is caring for a client who is experiencing extreme mania due to bipolar disorder. Prior to administration of lithium carbonate, the client's lithium blood level is 1.2 mEq/L. Which of the following actions should the nurse take?

Administer the next dose of lithium carbonate as scheduled.

A nurse is caring for an adult client who has injuries resulting from intimate partner abuse. The client does not wish to report the violence to law enforcement authorities. Which of the following actions is the highest priority?

Advise the client about the location of women's shelters.

A nurse is discussing the risk factors for somatic symptom disorder with a newly licensed nurse. Which of the following risk factors should the nurse include?

Anxiety disorder, female gender

A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?

Assessing the client's risk for self harm.

A nurse observes a client who has OCD repeatedly applying, removing and reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

Attempt to reduce anxiety.

A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?

Bipolar disorder with rapid cycling

Beta blockers

Block epinephrine, decrease HR

Syndromes seen in other cultures but not seen in our own, such as piblokto, Navajo frenzy witchcraft, and amok should be considered:

Culture-bound syndromes that are not dissociative disorders

A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching?

Difficulty sleeping can indicate a relapse, participating in psychotherapy can help prevent a relapse, anhedonia is a clinical manifestation of a depressive relapse.

A nurse is reviewing the medical record of a client who has conversion disorder Which of the following findings should the nurse identify as placing the client at risk for conversion disorder?

Death of a child 2 months ago

Tyler is being discharged home to his family. Which of the following is important teaching to include for the patient and the family to recognize possible signs of impending mania?

Decreased sleep

A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence?

Defensive responses, facial grimacing, agitation.

A nurse is teaching a newly licensed nurse about the use of ECT for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?

ECT is prescribed to prevent relapse of bipolar disorder.

Which of the following describe the symptoms of the manic phase of bipolar disorder? (select all that apply):

Excessive energy, pressured speech, purposeless movement, racing thoughts, distractibility

A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?

Excessive worry for 6 months, restlessness, need for reassurance.

Hallie's father, Brent, has now been diagnosed with PTSD as well as Hallie. Which of the following symptoms would lead a provider to suspect PTSD? (select all that apply):

Flashbacks of the accident, hypervigilance, irritability, difficulty concentrating

SSRI & SNRI

Fluoxetine (Prozac) Sertraline (Zoloft) Escitalopram (Lexapro) Duloxetine (Cymbalta)- SNRI

Tyler is a 31-year-old patient admitted with acute mania. He tells the staff and the other patients that he is on a secret mission given to him by the President of the United States to monitor citizens for terrorist activity. He states, "I am the only one he trusts, because I am the best!" For documentation purposes you know that this behavior is referred to as:

Grandiosity

Sasha has been having angry outbursts with staff and peers on the unit. You are talking with Sasha on her third day of admission. You ask whether she is having any thoughts of suicide. Sasha becomes angry and defensive, shouting, "I'm sick of you people! Are you ever do is ask me the same question over and over. Get out of here!" Your response is based on the knowledge that:

Sasha may be at high risk for self-harm

Jermaine attempted suicide while intoxicated by using a gun, although the bullet missed when he staggered. Jermaine's method of using a gun to attempt suicide is considered:

High risk, or a hard method

Jermaine scores a 7 on the SAD PERSONS scale. What action needs to be taken?

Hospitalize or commit

Symptoms of serotonin syndrome

Hyper reflex is, tremor, clonus, increased bowel sounds, autonomic instability, agitation, diaphoresis, tachycardia

A nurse working in an outpatient clinic is providing teaching to a client who has premenstrual dysphoric disorder. Which of the following statements by the client indicates understanding of the teaching?

I am aware that my PMDD causes me to have rapid mood swings.

A nurse is providing teaching to a client who has new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

I may feel drowsy for a few weeks after starting this medication.

A nurse is counseling a client who has factitious disorder imposed on another. Which of the following client statements should the nurse expect?

I needed to make my son sick so that someone else would take care of him for awhile.

You are talking with Jennifer, a patient admitted with depression. Which statement by the patient indicates the need for further assessment?

I think things will get better soon

A nurse is discussing the care of a client following a sexual assault with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

I will administer prophylactic treatment for sexually transmitted infections, like chlamydia.

A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?

I will receive a muscle relaxant to protect me from injury during ECT.

A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

I will schedule the client for daily TMS treatments for the first several weeks.

A nurse is preparing a community education seminar about family violence. When discussing types of violence, the nurse should include which of the following?

Intentionally causing an older adult to fall is an example of physical violence.

Uses for SSRI

Major depression, OCD, anxiety disorders, panic, PTSD, bulima

A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect?

Memory loss, nausea, confusion

A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?

Monitor the client for escalating behavior

A nurse is caring for a client in an inpatient mental health facility who gets up from a chair and throws it across the room. Which of the following is the priority nursing action?

Move the client away from others.

A nurse is admitting a client who has a new diagnosis of bipolar disorder and is scheduled to begin lithium therapy. When collecting a medical history from the client's adult daughter, which of the following statements is the priority to report tot he provider?

My mother is currently on furosemide for her congestive heart failure.

A nurse is assessing a client who has illness anxiety disorder. Which of the following findings should the nurse expect?

Obsessive thoughts about disease, history of childhood abuse, avoidance of health care providers, depressive disorder.

A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care?

Offer concise explanations, establish consistent limits, use a firm approach with communication

A nurse is caring for a client who is taking phenelzineu. For which of the following adverse effects should the nurse monitor?

Orthostatic hypotension, headache

Hallie, 4 years old, is referred to the outpatient mental health clinic after being in a severe car accident during which her father was driving and her mother died. Her father states she is withdrawn, not sleeping, having nightmares, and acts out the car accident over and over again when playing. Hallie states to you, "It's my fault because I'm bad." You suspect:

PTSD

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurses priority?

Placing the client on one-to-one observation

A nurse is discussing early indications of toxicity with a client who has a new prescription for lithium carbonate for bipolar disorder. The nurse should include which of the following manifestations in the teaching?

Polyuria, muscle weakness

A charge nurse is leading a peer group discussion about family and community violence. Which of the following statements by a member of the group indicates an understanding of the teaching?

Pregnancy increases the risk for violence toward the intimate partner.

A nurse is interviewing a 25 year old client who has a new diagnosis of dysthymic disorder. Which of the following findings should the nurse expect?

Presence of manifestations for at least 2 years.

A nurse is caring for a client who is prescribed lithium therapy. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make?

Regular aspirin would be a better choice than ibuprofen.

Which of the following statements is true regarding culture and protective factors against suicide?

Religion and the importance of family are protective factors for Hispanic Americans.

A nurse is caring for a client who is speaking in a loud voice with clenched fists. Which of the following actions should the nurse take?

Request that other staff members remain close by.

A nurse is caring for a client who is screaming at staff members and other clients. Which of the following is a therapeutic response by the nurse to the client?

Stop screaming, and walk with me outside.

Which of the following is true of the relationship between bipolar disorder and suicide?

Suicide is a serious risk because nearly 20% of those diagnosed with bipolar disorder commit suicide.

A nurse is reviewing the medical record of a client who has a new prescription for bupropion for depression. Which of the following findings is the priority for the nurse to report to the provider?

The client had a motor vehicle crash last year and sustained a head injury.

A charge nurse is discussing the care of a client who has major depressive disorder with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

The client is at greatest risk for suicide during the first weeks of a MDD episode.

A charge nurse is discussing mirtazapine with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

This medication increases the release of serotonin and norepinephrine.

A nurse is teaching a client who has a new prescription for imipramine how to minimize anticholinergic effects. Which of the following instructions should the nurse include in the teaching?

Void just before taking the medication, wear sunglasses when outside, chew sugarless gum.

A nurse is caring for a client who was recently raped. The client states, "I never should have been out on the street alone at night." Which of the following responses should the nurse make?

You believe this wouldn't have happened if you hadn't been out alone?

A nurse is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication?

You'd better listen to me.

A nurse is assessing a client who experienced sexual assault. Which of the following findings indicate the client is experiencing an emotional reaction of rape-trauma syndrome

emotional outbursts, difficulty making decisions

A nurse is discussing silent rape reaction with a newly licensed nurse. The nurse should identify which of the following characteristics as expected for this type of reaction?

sudden development of phobias, increased level of anxiety during interview, unwillingness to discuss the sexual assault.

The major reason for hospitalization for depressed patients is:

suicidal ideation